Comparing the alcohol-related problems survey (ARPS) to traditional alcohol screening measures in elderly outpatients

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Abstract

Older drinkers may incur alcohol-related risks at low consumption levels, but commonly used screening measures do not address alcohol's effects among persons with declining health and increased medication use. We compared the newly developed Alcohol-Related Problems Survey (ARPS) to three validated alcohol screens: the Cut down, Annoyed, Guilty, Eye-opener (CAGE), Short-Michigan Alcohol Screening Test (SMAST), and Alcohol-Use Identification Test (AUDIT). The ARPS classifies drinking as non-hazardous, hazardous or harmful. Non-hazardous drinking is defined as consumption with no known risks for adverse physical or psychological health events. Hazardous drinking is consumption with such risks. Harmful drinking results in adverse events. The AUDIT screens for hazardous and harmful drinking; the CAGE and SMAST identify abusive (e.g. failure to fulfill social obligations) and dependent (e.g. having withdrawal symptoms) drinkers. In this study of 574 current drinkers 65 years and older who completed the ARPS and AUDIT in primary care clinics, half were randomly assigned to complete the CAGE and half, the SMAST. Drinkers who screened positive on the CAGE, SMAST or AUDIT were correctly classified by the ARPS as hazardous or harmful drinkers 91, 75, and 100% of the time, respectively. The majority of ARPS-identified hazardous or harmful drinkers did not screen positive on the CAGE, SMAST or AUDIT. These drinkers had medical conditions or used medications that placed them at risk for adverse health events, none of which was addressed in these three screens. In this study, the ARPS identified nearly all drinkers detected by the CAGE, SMAST, and AUDIT and detected hazardous and harmful drinkers not identified by these measures.

Introduction

Alcohol-related problems in persons 65 years of age and older are a growing public health concern. Population-based studies, using various methods and diverse settings, estimate the prevalence of current alcohol-related problems in older Americans to range from 2 to 22%, with between 4 and 10% actively alcoholic (Adams and Cox, 1995). As the elderly population grows, the absolute number of older adults with alcohol-related problems will also rise, contributing to the magnitude of this public health issue. By at least one calculation (Widner and Zeichner, 1991), there will be 50% more elderly alcoholics in the U.S. in the next decades than at the end of the 1970s even if the rate of alcohol abuse remains unchanged. A 1989 study of Medicare claims data (Adams et al., 1993) found that the rate of alcohol-related hospitalizations (e.g. for alcohol dependence and alcoholic liver disease) among people 65 years of age and older was similar to that for myocardial infarction.

Older adults may experience adverse health effects even at relatively low levels of consumption because of age-related physiological changes (Dufour and Fuller, 1995) and the interaction between alcohol, declining health, medication-use and diminishing functional status (Moore et al., 1999). Relatively low consumption levels can adversely affect chronic medical problems common in older persons such as hypertension (Klatsky et al., 1986) and diabetes (Holbrook et al., 1990) and increase the difficulty of managing them. More than 75% of older adults regularly use medications (Chrischilles et al., 1992) many of which (such as non-steroidal anti-inflammatory agents or anti-hypertensives) have the potential to interact adversely with alcohol (Lieber, 1992, Forster et al., 1993, Adams, 1995).

The importance of detecting and preventing alcohol-related problems in older adults has been acknowledged by most public and private agencies including the National Institute on Alcohol Abuse and Alcoholism (1995), the American Medical Association (1995) and the American Geriatrics Society (1997). The majority of older adults receive their health care from primary care providers. Curtis et al. (1989) and Buchsbaum et al. (1992a) have demonstrated, however, that alcohol problems are often undetected by primary care providers, especially in the elderly. Among the major reasons for this has been the lack of provider education regarding alcohol use and, until recently, the unavailability of screening tests designed specifically for community-dwelling older persons (Graham, 1986, Fink et al., 1996).

The Alcohol-Related Problems Survey (ARPS) is a newly developed alcohol screening measure for older adults. It differs from other screens in its emphasis on the relationship between alcohol consumption and declining health, medication-use and diminishing functional status. Other screens focus on quantity and frequency of use, personal feelings about use (e.g. guilt feelings) and consequences of use (legal, social, and emotional). The ARPS' intended audience is community dwelling older adults who currently drink. It aims to raise the awareness of physicians and their patients of the potential for alcohol-related problems that exist even at low consumption levels because of the physiological and pathological changes associated with aging.

Traditionally, primary care health care providers have relied on screening measures like the CAGE (Mayfield et al., 1974, Ewing, 1984), the MAST (Selzer, 1971), and its variants including the SMAST (Selzer et al., 1975) and MAST–Geriatric Version (Blow, 1991), and the Alcohol Use Disorders Identification Test or AUDIT (Saunders and Aasland, 1987, Babor et al., 1989). The CAGE questionnaire is perhaps the best known screening measure for alcohol abuse or dependence; it has been validated using Diagnostic and Statistical Manual of Mental Disorders criteria (American Psychiatric Association, 1994) as a criterion standard. The MAST was also developed to detect alcohol abuse and dependence and focuses on patients' drinking behavior and the adverse consequences or personal concerns that arise from their alcohol consumption. Neither the CAGE nor the MAST and its variants (e.g. MAST–Geriatric Version) is designed to address the effects of alcohol use in combination with disease, medication-use, and function.

The purposes of this study were to compare the ARPS in detecting alcohol abuse and dependence when compared to the CAGE and SMAST and in identifying hazardous and harmful drinking when compared to the AUDIT. It is customary to compare new measures like the Alcohol-Related Problems Survey to more traditional measures in order to examine the new measure's advantages and limitations. We compared the ARPS to the 13-item SMAST rather than the longer 24-item MAST to reduce respondent burden. We hypothesized that the ARPS, CAGE and SMAST would detect equal numbers of abusive and dependent drinkers, and that the ARPS and AUDIT would detect equal numbers of hazardous and harmful drinkers. We also compared the CAGE, SMAST, and AUDIT to the ARPS in identifying hazardous and harmful drinkers defined as those who were at risk for, or experiencing harm from the interactions between alcohol consumption and medical conditions, medication-use, and functional status. We hypothesized that the ARPS would identify these hazardous or harmful drinkers who were not detected by the other screening measures.

Section snippets

Definitions of non-hazardous, hazardous, and harmful drinking

We defined a drink as any one of the following: one 12 ounce bottle or can of beer; one 12 ounce bottle of wine cooler; one 5-ounce glass of wine; one 1.5 ounce shot of hard liquor; or one cocktail containing 1.5 ounces of hard liquor. The study's definitions of non-hazardous, hazardous and harmful drinking in elders come from an Expert Panel that used standardized consensus development methods including a formal literature review (Fink et al., 1996), in-person discussions, and a three-round

Sample

The average age of the subjects was 75 years (65–100 years) (Table 1). Subjects were predominately male (56%) and non-Hispanic white (87%). The study group was well educated, with 96% having completed high school, and 64% having an average household income of at least $25,000 per year. Eighty-one percent of the sample took at least one medication (such as an antihypertensive) that can interact adversely with alcohol. Twenty-five percent of the subjects reported being limited in functional

Discussion and conclusions

The ARPS is comparable to the CAGE and SMAST in identifying abusive and dependent drinkers. It is also comparable to the AUDIT in identifying hazardous and harmful drinkers. In addition, the ARPS identifies hazardous and harmful elderly drinkers who are likely to be overlooked by the CAGE, SMAST and AUDIT. These drinkers are at-risk for or already have alcohol-related problems because of the potential for adverse effects resulting from alcohol use combined with declining health, medication-use,

Acknowledgements

The authors are most grateful to all participating patients at the UCLA Medical Center and Sansum–Santa Barbara Medical Foundation Clinics. We are deeply indebted to Dr William F. Gebhart and Bonnie Parsons, R.N. for their assistance. This study was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA: Contract #N44AA52009) and the John A. Hartford Foundation/American Federation for Aging Research Medical Student Geriatric Scholars Program (Mark Tsai).

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